Medical monitoring and treatment device with external pacing

ABSTRACT

A non-invasive bodily-attached ambulatory medical monitoring and treatment device with pacing is provided. The noninvasive ambulatory pacing device includes a battery, at least one therapy electrode coupled to the battery, a memory storing information indicative of a patient&#39;s cardiac activity, and at least one processor coupled to the memory and the at least one therapy electrode. The at least one processor is configured to identify a cardiac arrhythmia within the information and execute at least one pacing routine to treat the identified cardiac arrhythmia.

RELATED APPLICATIONS

This application claims the benefit under 35 U.S.C. §120 as acontinuation of U.S. application Ser. No. 13/907,523 titled “MEDICALMONITORING AND TREATMENT DEVICE WITH EXTERNAL PACING” filed on May 31,2013, which claims priority under 35 U.S.C. §119(e) to U.S. ProvisionalApplication Ser. No. 61/653,889, titled “NONINVASIVE AMBULATORYMONITORING AND TREATMENT DEVICE WITH EXTERNAL PACING,” filed on May 31,2012, each of which is hereby incorporated herein by reference in itsentirety.

BACKGROUND OF THE INVENTION

1. Technical Field

The present invention is directed to noninvasive ambulatory medicaldevices, and more particularly, to a non-invasive medical monitoring andtreatment device that is capable of externally pacing the heart of apatient wearing the device.

2. Discussion of the Related Art

Cardiac arrest and other cardiac health ailments are a major cause ofdeath worldwide. Various resuscitation efforts aim to maintain thebody's circulatory and respiratory systems during cardiac arrest in anattempt to save the life of the victim. The sooner these resuscitationefforts begin, the better the victim's chances of survival.

To protect against cardiac arrest and other cardiac health ailments,some at-risk patients may use a wearable defibrillator, such as theLifeVest® wearable cardioverter defibrillator available from ZOLLMedical Corporation of Chelmsford, Mass. To remain protected, thepatient wears the device nearly continuously while going about theirnormal daily activities, while awake, and while asleep.

SUMMARY OF THE INVENTION

Some aspects and embodiments of the present invention administerexternal pacing to the heart using a non-invasive bodily-attachedambulatory medical monitoring and treatment device (hereinafter referredto as a “medical monitoring and treatment device”). As used herein, theterm non-invasive means that the device does not penetrate the body of apatient. This is in contrast to invasive devices, such as implantablemedical devices, in which at least a portion of the device is disposedsubcutaneously. The term bodily-attached means that at least a portionof the device (other than its electrodes in the case of a defibrillator,cardioverter or pacer) is removably attached to the body of a patient,such as by mechanical coupling (for example, by a wrist strap, cervicalcollar, bicep ring), adhesion (for example, by an adhesive gelintermediary), suction, magnetism, fabric or other flexible material(for example, by straps or integration into a garment) or other bodymounting features not limited by the aforementioned examples. Thesecoupling elements hold the device in a substantially fixed position withrespect to the body of the patient. The term ambulatory means that thedevice is capable of and designed for moving with the patient as thepatient goes about their daily routine.

One example of a medical monitoring and treatment device is theLifeVest® Wearable Cardioverter Defibrillator available from ZOLLMedical Corporation of Chelmsford, Mass. A medical monitoring andtreatment device can provide life saving defibrillation treatment to apatient suffering a treatable form of cardiac arrhythmia such asVentricular Fibrillation (VF) or Ventricular Tachycardia (VT).Applicants have appreciated that such a medical monitoring and treatmentdevice can be configured to perform a variety of different types ofcardiac pacing to treat a wide variety of different cardiac arrhythmias,such as bradycardia, tachycardia, an irregular cardiac rhythm, andasystole (including asystole after a shock). Applicants have furtherappreciated that, in other embodiments, a medical monitoring andtreatment device can be configured to perform pacing to treat pulselesselectrical activity. In accordance with an aspect of the presentinvention, the medical monitoring and treatment device can be configuredto pace the heart of the patient at a fixed energy level (e.g., fixedcurrent, fixed voltage, etc. . . . ) and pulse rate, to pace the heartof the patient on demand with a fixed energy level and an adjustablerate responsive to the detected intrinsic activity level of thepatient's heart, or to pace the heart of the patient using capturemanagement with an adjustable energy level and adjustable rateresponsive to the detected intrinsic rate of the patient's heart and thedetected response of the patient's heart to pacing, including both on abeat-by-beat basis and as analyzed over other various time intervals.

According to some embodiments, a medical monitoring and treatment deviceis provided. The medical monitoring and treatment device includes abattery, at least one therapy electrode coupled to the battery, a memorystoring information indicative of a patient's cardiac activity, and atleast one processor coupled to the memory and the at least one therapyelectrode. The at least one processor is configured to identify acardiac arrhythmia within the information and execute at least onepacing routine to treat the identified cardiac arrhythmia.

In the medical monitoring and treatment device, the cardiac arrhythmiathat the at least one processor is configured to identify may includebradycardia and the at least one pacing routine may be configured todetermine that a first interval has passed without detection of a heartbeat and apply, responsive to determining that the first interval haspassed, a pacing pulse via the at least one therapy electrode. The firstinterval may be defined by a base pacing rate and a hysteresis rate. Theat least one pacing routine may be further configured to detect anintrinsic heart beat prior to passage of a second interval; determine athird interval based on the base pacing rate, the hysteresis rate, and apoint where the intrinsic heart beat was detected; and determine whetheranother intrinsic heart beat occurs within the third interval.

In the medical monitoring and treatment device, the cardiac arrhythmiathat the at least one processor is configured to identify may includetachycardia and the at least one pacing routine may be configured todetect a plurality of intrinsic heart beats prior to passage of a firstinterval, the plurality of intrinsic heart beats having an intrinsicfrequency, the first interval being defined by an anti-tachyarrhythmicpacing rate and apply, responsive to detecting the intrinsic frequency,a series of pacing pulses via the at least one therapy electrode, theseries of pacing pulses having a frequency above the intrinsicfrequency. The at least one pacing routine may be further configured todetect, after applying the series of pacing pulses, whether anotherplurality of intrinsic heart beats occur within a second interval, thesecond interval being defined by the anti-tachyarrhythmic pacing rate.

In the medical monitoring and treatment device, the cardiac arrhythmiathat the at least one processor is configured to identify may include anerratic heart rate and the at least one pacing routine may be configuredto identify a first series of heart beats within the information, thefirst series having a lower frequency; identify a second series of heartbeats within the information, the second series a upper frequency; andapply, responsive to identifying the erratic heart rate, a series ofpacing pulses via the at least one therapy electrode, the series ofpacing pulses having a frequency above the lower frequency and below theupper frequency.

In the medical monitoring and treatment device, the cardiac arrhythmiathat the at least one processor is configured to identify may include atleast one of asystole and pulseless electrical activity and the at leastone pacing routine may be configured to determine that a first intervalhas passed without detection of a heart beat; and apply, responsive todetermining that the first interval has passed, a pacing pulse via theat least one therapy electrode. The at least on pacing routine may befurther configured to apply a defibrillating shock prior to applying thepacing pulse.

In the medical monitoring and treatment device, the at least one pacingroutine may be further configured to determine whether the at least onepacing routine resulted in capture and adjust, responsive to determiningthat capture did not result, the characteristics of pacing pulsesapplied during subsequent executions of the at least one pacing routine.The characteristics of the pacing pulses subject to adjustment mayinclude a pulse energy level, a pulse rate, and a pulse width.

In the medical monitoring and treatment device, the at least one pacingroutine is further configured to determine whether the at least onepacing routine resulted in capture; and adjust, responsive todetermining that capture did result, the characteristics of pacingpulses applied during subsequent executions of the at least one pacingroutine.

According to other embodiments, a non-invasive bodily-attachedambulatory wearable defibrillator is provided. The non-invasivebodily-attached ambulatory wearable defibrillator includes a battery, atleast one therapy electrode coupled to the battery, a memory storinginformation indicative of a patient's cardiac activity, and at least oneprocessor coupled to the memory and the at least one therapy electrode.The at least one processor is configured to identify a cardiacarrhythmia within the information and execute at least one pacingroutine to treat the identified cardiac arrhythmia.

In the non-invasive bodily-attached ambulatory defibrillator, thecardiac arrhythmia that the at least one processor is configured toidentify may include bradycardia and the at least one pacing routine maybe configured to determine that a first interval has passed withoutdetection of a heart beat and apply, responsive to determining that thefirst interval has passed, a pacing pulse via the at least one therapyelectrode. The first interval may be defined by a base pacing rate and ahysteresis rate. The at least one pacing routine may be furtherconfigured to detect an intrinsic heart beat prior to passage of asecond interval; determine a third interval based on the base pacingrate, the hysteresis rate, and a point where the intrinsic heart beatwas detected; and determine whether another intrinsic heart beat occurswithin the third interval.

In the non-invasive bodily-attached ambulatory defibrillator, thecardiac arrhythmia that the at least one processor is configured toidentify may include tachycardia and the at least one pacing routine maybe configured to detect a plurality of intrinsic heart beats prior topassage of a first interval, the plurality of intrinsic heart beatshaving an intrinsic frequency, the first interval being defined by ananti-tachyarrhythmic pacing rate; and apply, responsive to detecting theintrinsic frequency, a series of pacing pulses via the at least onetherapy electrode, the series of pacing pulses having a frequency abovethe intrinsic frequency. The at least one pacing routine may be furtherconfigured to detect, after applying the series of pacing pulses,whether another plurality of intrinsic heart beats occur within a secondinterval, the second interval being defined by the anti-tachyarrhythmicpacing rate.

In the non-invasive bodily-attached ambulatory defibrillator, thecardiac arrhythmia that the at least one processor is configured toidentify may include an erratic heart rate and the at least one pacingroutine may be configured to identify a first series of heart beatswithin the information, the first series having a lower frequency;identify a second series of heart beats within the information, thesecond series a upper frequency; and apply, responsive to identifyingthe erratic heart rate, a series of pacing pulses via the at least onetherapy electrode, the series of pacing pulses having a frequency abovethe lower frequency and below the upper frequency.

In the non-invasive bodily-attached ambulatory defibrillator, thecardiac arrhythmia that the at least one processor is configured toidentify may include at least one of asystole and pulseless electricalactivity and the at least one pacing routine may be configured todetermine that a first interval has passed without detection of a heartbeat and apply, responsive to determining that the first interval haspassed, a pacing pulse via the at least one therapy electrode. The atleast one pacing routine may be further configured to apply adefibrillating shock prior to applying the pacing pulse.

In the non-invasive bodily-attached ambulatory defibrillator, the atleast one pacing routine may be further configured to determine whetherthe at least one pacing routine resulted in capture and adjust,responsive to determining that capture did not result, thecharacteristics of pacing pulses applied during subsequent executions ofthe at least one pacing routine. The characteristics of the pacingpulses subject to adjustment may include a pulse energy level, a pulserate, and a pulse width.

In the non-invasive bodily-attached ambulatory defibrillator, the atleast one pacing routine may be further configured to determine whetherthe at least one pacing routine resulted in capture and adjust,responsive to determining that capture did result, the characteristicsof pacing pulses applied during subsequent executions of the at leastone pacing routine.

According to another embodiment, a method of treating cardiacdysfunction using a medical monitoring and treatment device with pacingis provided. The medical monitoring and treatment device may include anon-invasive bodily-attached ambulatory defibrillator. The methodincludes acts of identifying, by the medical monitoring and treatmentdevice, a cardiac arrhythmia within information indicative of apatient's cardiac activity; and executing, by the medical monitoring andtreatment device, at least one pacing routine to treat the identifiedcardiac arrhythmia.

In the method, where the cardiac arrhythmia includes bradycardia, theact of executing the at least one pacing routine may include acts ofdetermining that a first interval has passed without detection of aheart beat and applying, responsive to determining that the firstinterval has passed, a pacing pulse via the at least one therapyelectrode. The act of determining that the first interval has passed mayinclude an act of defining the first interval using a base pacing rateand a hysteresis rate. The act of executing the at least one pacingroutine may include acts of detecting an intrinsic heart beat prior topassage of a second interval; determining a third interval based on thebase pacing rate, the hysteresis rate, and a point where the intrinsicheart beat was detected; and determining whether another intrinsic heartbeat occurs within the third interval.

In the method, where the cardiac arrhythmia includes tachycardia, theact of executing the at least one pacing routine may include acts ofdetecting a plurality of intrinsic heart beats prior to passage of afirst interval, the plurality of intrinsic heart beats having anintrinsic frequency, the first interval being defined by ananti-tachyarrhythmic pacing rate and applying, responsive to detectingthe intrinsic frequency, a series of pacing pulses via the at least onetherapy electrode, the series of pacing pulses having a frequency abovethe intrinsic frequency.

In the method, where the cardiac arrhythmia includes an erratic heartrate, the act of executing the at least one pacing routine may includeacts of identifying a first series of heart beats within theinformation, the first series having a lower frequency; identifying asecond series of heart beats within the information, the second series aupper frequency; and applying, responsive to identifying the erraticheart rate, a series of pacing pulses via the at least one therapyelectrode, the series of pacing pulses having a frequency above thelower frequency and below the upper frequency.

In the method, where the cardiac arrhythmia includes at least one ofasystole and pulseless electrical activity, the act of executing the atleast one pacing routine may include acts of determining that a firstinterval has passed without detection of a heart beat; and applying,responsive to determining that the first interval has passed, a pacingpulse via the at least one therapy electrode. The act of executing theat least one pacing routine may include an act of applying adefibrillating shock prior to applying the pacing pulse.

In the method, the act of executing the at least one pacing routine mayinclude acts of determining whether the at least one pacing routineresulted in successful capture and adjusting, responsive to determiningthat capture did not result, the characteristics of pacing pulsesapplied during subsequent executions of the at least one pacing routine.The act of adjusting the characteristics may include an act of adjustingat least one of a pulse energy level, a pulse rate, and a pulse width.

Still other aspects, embodiments, and advantages of these exemplaryaspects and embodiments are discussed in detail below. Moreover, it isto be understood that both the foregoing information and the followingdetailed description are merely illustrative examples of various aspectsand embodiments of the present invention, and are intended to provide anoverview or framework for understanding the nature and character of theclaimed aspects and embodiments. Any embodiment disclosed herein may becombined with any other embodiment in any manner consistent with atleast one of the aspects disclosed herein, and references to “anembodiment,” “some embodiments,” “an alternate embodiment,” “variousembodiments,” “one embodiment,” “at least one embodiment,” “this andother embodiments” or the like are not necessarily mutually exclusiveand are intended to indicate that a particular feature, structure, orcharacteristic described in connection with the embodiment may beincluded in at least one embodiment. The appearance of such terms hereinis not necessarily all referring to the same embodiment.

Furthermore, in the event of inconsistent usages of terms between thisdocument and documents incorporated herein by reference, the term usagein the incorporated references is supplementary to that of thisdocument; for irreconcilable inconsistencies, the term usage in thisdocument controls. In addition, the accompanying drawings are includedto provide illustration and a further understanding of the variousaspects and embodiments, and are incorporated in and constitute a partof this specification. The drawings, together with the remainder of thespecification, serve to explain principles and operations of thedescribed and claimed aspects and embodiments.

BRIEF DESCRIPTION OF THE DRAWINGS

The accompanying drawings are not intended to be drawn to scale. In thedrawings, each identical or nearly identical component that isillustrated in various figures is represented by a like numeral. Forpurposes of clarity, not every component may be labeled in everydrawing. In the drawings:

FIG. 1 illustrates a medical monitoring and treatment device, such as awearable defibrillator;

FIG. 2 is a functional block diagram of one example of a portabletreatment controller that may be used in the medical monitoring andtreatment device of FIG. 1;

FIG. 3 illustrates a number of different pacing waveforms that may beprovided by the medical monitoring and treatment device, including a 40ms constant current pulse; and

FIG. 4 illustrates various aspects of demand pacing which can beadjusted in connection with on demand pacing or capture managementpacing.

DETAILED DESCRIPTION

This invention is not limited in its application to the details ofconstruction and the arrangement of components set forth in thefollowing description or illustrated in the drawings. The invention iscapable of other embodiments and of being practiced or of being carriedout in various ways. Also, the phraseology and terminology used hereinis for the purpose of description and should not be regarded aslimiting. The use of “including,” “comprising,” “having,” “containing,”“involving,” and variations thereof herein is meant to encompass theitems listed thereafter and equivalents thereof as well as additionalitems.

FIG. 1 illustrates a medical monitoring and treatment device, such as aLifeVest® Wearable Cardioverter Defibrillator available from ZOLLMedical Corporation of Chelmsford, Mass. As shown, the medicalmonitoring and treatment device 100 includes a harness 110 having a pairof shoulder straps and a belt that is worn about the torso of a patient.The harness 110 is typically made from a material, such as cotton,nylon, spandex, or antron that is breathable, and unlikely to cause skinirritation, even when worn for prolonged periods of time. The medicalmonitoring and treatment device 100 includes a plurality ofelectrocardiographic (ECG) sensing electrodes 112 that are disposed bythe harness 110 at various positions about the patient's body andelectrically coupled (wirelessly or by a wired connection) to a portabletreatment controller 120 via a connection pod 130. The plurality of ECGsensing electrodes 112 are used by the portable treatment controller 120to monitor the cardiac function of the patient and generally include afront/back pair of ECG sensing electrodes and a side/side pair of ECGsensing electrodes. It should be appreciated that additional ECG sensingelectrodes may be provided, and the plurality of ECG sensing electrodes112 may be disposed at varying locations about the patient's body. Inaddition, the plurality of ECG electrodes 112 may incorporate anyelectrode system, including conventional stick-on adhesive electrodes,dry-sensing capacitive ECG electrodes, radio transparent electrodes,segmented electrodes, or one or more long term wear electrodes that areconfigured to be continuously worn by a patient for extended periods(e.g., 3 or more days). One example of such a long term wear electrodeis described in co-pending Application Ser. No. 61/653,749, titled “LONGTERM WEAR MULTIFUNCTION BIOMEDICAL ELECTRODE,” filed May 31, 2012, whichis hereby incorporated herein by reference in its entirety.

The medical monitoring and treatment devices disclosed herein mayincorporate sundry materials arranged in a variety of configurations tomaintain a proper fit with the patient's body. For example, someembodiments include a garment as described in co-pending applicationSer. No. 13/460,250, titled “PATIENT-WORN ENERGY DELIVERY APPARATUS ANDTECHNIQUES FOR SIZING SAME,” filed Apr. 30, 2012, which is herebyincorporated herein by reference in its entirety. Thus embodiments arenot limited to the configuration and materials described above withreference to FIG. 1.

The medical monitoring and treatment device 100 also includes aplurality of therapy electrodes 114 that are electrically coupled to theportable treatment controller 120 via the connection pod 130 and whichare capable of delivering one or more therapeutic defibrillating shocksto the body of the patient, if it is determined that such treatment iswarranted. As shown, the plurality of therapy electrodes 114 includes afirst therapy electrode 114 a that is disposed on the front of thepatient's torso and a second therapy electrode 114 b that is disposed onthe back of the patient's torso. The second therapy electrode 114 bincludes a pair of therapy electrodes that are electrically coupledtogether and act as the second therapy electrode 114 b. The use of twotherapy electrodes 114 a, 114 b permits a biphasic shock to be deliveredto the body of the patient, such that a first of the two therapyelectrodes can deliver a first phase of the biphasic shock with theother therapy electrode acting as a return, and the other therapyelectrode can deliver the second phase of the biphasic shock with thefirst therapy electrode acting as the return. The connection pod 130electrically couples the plurality of ECG sensing electrodes 112 and theplurality of therapy electrodes 114 to the portable treatment controller120, and may include electronic circuitry. For example, in oneimplementation the connection pod 130 includes signal acquisitioncircuitry, such as a plurality of differential amplifiers to receive ECGsignals from different ones of the plurality of ECG sensing electrodes112 and to provide a differential ECG signal to the portable treatmentcontroller 120 based on the difference therebetween. The connection pod130 may also include other electronic circuitry, such as a motion sensoror accelerometer by which patient activity may be monitored.

In some embodiments, both the first therapy electrode 114 a and thesecond therapy electrode 114 b are disposed on the front of thepatient's torso. For example, the first therapy electrode 114 a may belocated at external to the apex of the heart and the second therapyelectrode 114 b may be located along the parasternal line. Thusembodiments are not limited to a particular arrangement of therapyelectrodes 114.

In some embodiments, the plurality of ECG sensing electrodes 112 arepositioned and paired such that artifacts generated from electricalactivity are decreased. In other embodiments, the electronic circuitryincluded in the portable treatment controller 120 may equalize artifactsmeasured at electrodes by changing a gain or impedance. Other techniquesof decreasing or preventing artifacts within measured electricalactivity that may be used in conjunction the embodiments disclosedherein are explained in U.S. Pat. No. 8,185,199, titled “MONITORINGPHYSIOLOGICAL SIGNALS DURING EXTERNAL ELECTRICAL STIMULATION,” issuedMay 22, 2012, which is incorporated by reference herein in its entirety.

As shown in FIG. 1, the medical monitoring and treatment device 100 mayalso include a user interface pod 140 that is electrically coupled tothe portable treatment controller 120. The user interface pod 140 can beattached to the patient's clothing or to the harness 110, for example,via a clip (not shown) that is attached to a portion of the interfacepod 140. Alternatively, the user interface pod 140 may simply be held ina person's hand. The user interface pod 140 typically includes one ormore actionable user interface elements (e.g., one or more buttons, afingerprint scanner, a touch screen, microphone, etc. . . . ) by whichthe patient, or a bystander can communicate with the portable treatmentcontroller 120, and a speaker by which the portable treatment controller120 may communicate with the patient or the bystander. In certain modelsof the LifeVest® Wearable Cardioverter Defibrillator, the functionalityof the user interface pod 140 is incorporated into the portabletreatment controller 120.

Where the portable treatment controller 120 determines that the patientis experiencing cardiac arrhythmia, the portable treatment controller120 may issue an audible alarm via a loudspeaker (not shown) on theportable treatment controller 120 and/or the user interface pod 140alerting the patient and any bystanders to the patient's medicalcondition. Examples of notifications issued by the portable treatmentcontroller 120 are described in co-pending application Ser. No.13/428,703, titled “SYSTEM AND METHOD FOR ADAPTING ALARMS IN A WEARABLEMEDICAL DEVICE,” filed Mar. 23, 2012, which is incorporated by referenceherein in its entirety. The portable treatment controller 120 may alsoinstruct the patient to press and hold one or more buttons on theportable treatment controller 120 or on the user interface pod 140 toindicate that the patient is conscious, thereby instructing the portabletreatment controller 120 to withhold the delivery of one or moretherapeutic defibrillating shocks. If the patient does not respond, thedevice may presume that the patient is unconscious, and proceed with thetreatment sequence, culminating in the delivery of one or moredefibrillating shocks to the body of the patient.

The portable treatment controller 120 generally includes at least oneprocessor, microprocessor, or controller, such as a processorcommercially available from companies such as Texas Instruments, Intel,AMD, Sun, IBM, Motorola, Freescale and ARM Holdings. In oneimplementation, the at least one processor includes a power conservingprocessor arrangement that comprises a general purpose processor, suchas an Intel® PXA270 processor and a special purpose processor, such as aFreescale DSP56311 Digital Signal Processor. Such a power conservingprocessor arrangement is described in co-pending application Ser. No.12/833,096, titled SYSTEM AND METHOD FOR CONSERVING POWER IN A MEDICALDEVICE, filed Jul. 9, 2010 (hereinafter the “'096 application”) which isincorporated by reference herein in its entirety. The at least oneprocessor of the portable treatment controller 120 is configured tomonitor the patient's medical condition, to perform medical data loggingand storage, and to provide medical treatment to the patient in responseto a detected medical condition, such as cardiac arrhythmia.

Although not shown, the medical monitoring and treatment device 100 mayinclude additional sensors, other than the ECG sensing electrodes 112,capable of monitoring the physiological condition or activity of thepatient. For example, sensors capable of measuring blood pressure, heartrate, heart sounds, thoracic impedance, pulse oxygen level, respirationrate, and the activity level of the patient may also be provided.

FIG. 2 illustrates a portable treatment controller 120 that isconfigured to perform the critical functions of monitoring physiologicalinformation for abnormalities and initiating treatment of detectedabnormalities. As shown, the portable treatment controller 120 caninclude the power conserving processor arrangement 200 described in the'096 application, a sensor interface 212, a therapy delivery interface202, data storage 204, a communication network interface 206, a userinterface 208 and a battery 210. In this illustrated example, thebattery 210 is a rechargeable 3 cell 2200 mAh lithium ion battery packthat provides electrical power to the other device components with aminimum 24 hour runtime between charges. Such a battery 210 hassufficient capacity to administer one or more therapeutic shocks and thetherapy delivery interface 202 has wiring suitable to carry the load tothe therapy electrodes 114. Moreover, in the example shown, the battery210 has sufficient capacity to deliver up to 5 or more therapeuticshocks, even at battery runtime expiration. The amount of power capableof being delivered to a patient during a defibrillating shock issubstantial, for example up to approximately 200 Joules.

The sensor interface 212 and the therapy delivery interface 202 arecoupled to the power conserving processor arrangement 200 and moreparticularly to the critical purpose processor of the power conservingprocessing arrangement 200 as described in the '096 application. Thedata storage 204, the network interface 206, and the user interface 208are also coupled to the power conserving processor arrangement 200, andmore particularly to the general purpose processor of the powerconserving processing arrangement as also described in the '096application.

In the example shown, the data storage 204 includes a computer readableand writeable nonvolatile data storage medium configured to storenon-transitory instructions and other data. The medium may, for example,be optical disk, magnetic disk or flash memory, among others and may bepermanently affixed to, or removable from, the portable treatmentcontroller 120.

As shown in FIG. 2, the portable treatment controller 120 includesseveral system interface components 202, 206 and 212. Each of thesesystem interface components is configured to exchange, i.e., send orreceive data, with specialized devices that may be located within theportable treatment controller 200 or elsewhere. The components used bythe interfaces 202, 206 and 212 may include hardware components,software components or a combination of both. In the instance of eachinterface, these components physically and logically couple the portabletreatment controller 200 to one or more specialized devices. Thisphysical and logical coupling enables the portable treatment controller120 to both communicate with and, in some instances, control theoperation of specialized devices. These specialized devices may includephysiological sensors, therapy delivery devices, and computer networkingdevices.

According to various examples, the hardware and software components ofthe interfaces 202, 206 and 212 employ a variety of coupling andcommunication techniques. In some examples, the interfaces 202, 206 and212 use leads, cables or other wired connectors as conduits to exchangedata between the portable treatment controller 120 and specializeddevices. In other examples, the interfaces 202, 206 and 212 communicatewith specialized devices using wireless technologies such as radiofrequency or infrared technology. The software components included inthe interfaces 202, 206 and 212 enable the power conserving processorarrangement 200 to communicate with specialized devices. These softwarecomponents may include elements such as objects, executable code andpopulated data structures. Together, these hardware and softwarecomponents provide interfaces through which the power conservingprocessor arrangement 200 can exchange information with the specializeddevices. Moreover, in at least some examples where one or morespecialized devices communicate using analog signals, the interfaces202, 206 and 212 can include components configured to convert analoginformation into digital information, and vice-versa.

As discussed above, the system interface components 202, 206 and 212shown in the example of FIG. 2 support different types of specializeddevices. For instance, the components of the sensor interface 212 couplethe power conserving processor arrangement 200 to one or morephysiological sensors such as a body temperature sensors, respirationmonitors and dry-capacitive ECG sensing electrodes. It should beappreciated that other types of ECG sensing electrodes may be used, asthe present invention is not limited to any particular type of ECGsensing electrode. The components of the therapy delivery interface 202couple one or more therapy delivery devices, such as capacitors anddefibrillator electrodes, to the power conserving processor arrangement200. In addition, the components of the network interface 206 couple thepower conserving processor arrangement to a computer network via anetworking device, such as a bridge, router or hub. The networkinterface 206 may supports a variety of standards and protocols,examples of which include USB, TCP/IP, Ethernet, Wireless Ethernet,Bluetooth, ZigBee, M-Bus, IP, IPV6, UDP, DTN, HTTP, FTP, SNMP, CDMA,NMEA and GSM. To ensure data transfer is secure, in some examples, theportable treatment controller 200 can transmit data via the networkinterface 206 using a variety of security measures including, forexample, TSL, SSL or VPN. In other examples, the network interface 206includes both a physical interface configured for wireless communicationand a physical interface configured for wired communication.

The user interface 208 shown in FIG. 2 includes a combination ofhardware and software components that allow the portable treatmentcontroller 200 to communicate with an external entity, such as a user.These components are configured to receive information from actions suchas physical movement, verbal intonation or thought processes. Inaddition, the components of the user interface 208 can provideinformation to external entities. Examples of the components that may beemployed within the user interface 208 include keyboards, mouse devices,trackballs, microphones, electrodes, touch screens, printing devices,display screens and speakers.

The LifeVest® wearable cardioverter defibrillator can monitor apatient's ECG signals, detect various cardiac arrhythmias, and providelife saving defibrillation treatment to a patient suffering a treatableform of cardiac arrhythmia such as Ventricular Fibrillation (VF) orVentricular Tachycardia (VT).

Applicants have appreciated that such a medical monitoring and treatmentdevice can be configured to perform a variety of different types ofcardiac pacing to treat a wide variety of different cardiac arrhythmias,such as bradycardia, tachycardia, an irregular cardiac rhythm, orasystole. Applicants have further appreciated that, in otherembodiments, a medical monitoring and treatment device can be configuredto perform pacing to treat pulseless electrical activity. In accordancewith an aspect of the present invention, the device can be configured topace the heart of the patient at a fixed energy level and pulse rate, topace the heart of the patient on demand with a fixed energy level and anadjustable rate responsive to the detected intrinsic activity level ofthe patient's heart, or to pace the heart of the patient using capturemanagement with an adjustable energy level and rate responsive to thedetected intrinsic activity level of the patient's heart and thedetected response of the patient's heart. The various types of pacingmay be applied to the patient externally by one or more of the therapyelectrodes 114 a, 114 b (FIG. 1). Various types of pacing that can beperformed by a medical monitoring and treatment device, such as theLifeVest® wearable cardioverter defibrillator, can include asynchronouspacing at a fixed rate and energy, pacing on demand at a variable rateand fixed energy, and capture management pacing with an adjustable rateand adjustable energy level.

In some embodiments, the medical monitoring and treatment device isconfigured to periodically assess the level of discomfort of the patientduring pacing operation. In these embodiments, responsive to determiningthat the patient's discomfort level exceeds a threshold, the deviceattempts to adjust the attributes of the pacing activity to lessen thediscomfort experienced by the patient.

In one embodiment, the medical monitoring and treatment device providesa user interface through which the device receives informationdescriptive of the discomfort level experienced by a patient. Shouldthis information indicate that the level of discomfort has transgresseda threshold level, the device adjusts characteristics of the pacingoperation in an attempt to decrease the level of discomfort.

In another embodiment, the medical monitoring and treatment deviceassesses the level of discomfort of the patient by monitoring andrecording the patient's movement before, during, and afteradministration of a pacing pulse. The device may monitor the patient'smovement using a variety of instrumentation including, for example, oneor more accelerometers, audio sensors, etc. To assess the level ofdiscomfort experienced by the patient during pacing pulses, the devicemay analyze the recorded history of the patient's movement and identifycorrelations between changes in the patient's movement and the pacingpulse. Strong correlations between pacing pulses and sudden patientmovement, which may be representative of a flinch, and strongcorrelations between pacing pulses and a sudden stoppage of movement,may indicate that a patient is experiencing discomfort. Correlationshaving a value that transgresses a threshold value may be deemed toindicate discomfort and may cause the device to adjust thecharacteristics of a pacing pulse.

In other embodiments, the device adjusts the characteristics of thepacing operation to lessen the discomfort level of the patient. Thecharacteristics of the pacing operation that may be adjusted include,for example, the energy level of pacing pulses, the width of the pacingpulses, and the rate of the pacing pulses. In some embodiments, thedevice monitors the cardiac activity of the patient during thisadjustment process to ensure that the pacing operation continues toeffectively manage cardiac function. In these embodiments, the devicemay revert the characteristics of the pacing operation to their previoussettings, should the pacing operation become ineffective.

1. Fixed Rate and Energy Pacing

In accordance with an aspect of the present invention, a medicalmonitoring and treatment device, such as the LifeVest® wearablecardioverter defibrillator, can be configured to pace the heart of apatient at a fixed rate and fixed energy in response to various types ofcardiac arrhythmias. Examples of these cardiac arrhythmias includebradyarrythmia, a lack of sensed cardiac activity (spontaneous or postshock asystole) and pulseless electrical activity. In some cases, thesecardiac arrhythmias may occur before or after one or more defibrillationshocks. For example, the device may be configured to provide pulses at afixed energy level, a fixed pulse width, and a fixed frequency inresponse to detection of any of the above-noted events by the ECGsensing electrodes 112. The energy level of the pacing pulses may be setto a fixed value by applying a desired current waveform for a determinedduration of time by one or more of the therapy electrodes 114 a, 114 b.The maximum current level of the current waveform may be set to a valuebetween approximately 0 mAmps to 200 mAmps, the pulse width may be setto a fixed value between approximately 0.05 ms to 2 ms, and thefrequency of the pulses may be set to a fixed value betweenapproximately 30 pulses per minute (PPM) to approximately 200 PPM. Inaccordance with one embodiment, a 40 ms square wave pulse is used.Exemplary pacing current waveforms, including a 40 ms constant currentpulse, a 5 ms constant current pulse, and a variable current pulse areshown in FIG. 3.

During pacing operation of the medical monitoring and treatment device,the device may periodically pause for a period of time to evaluate thepatient via the ECG sensing electrodes to determine whether a normalsinus rhythm has returned. Where the device detects a normal sinusrhythm, the device may discontinue the application of pacing pulses andsimply continue monitoring the patient's physiological signals, such asthe patient's ECG, temperature, pulse oxygen level, etc.

During an initial fitting of the medical monitoring and treatmentdevice, the level of current, the pulse width, and the frequency of thepulses may be set to an appropriate level based on the input of amedical professional (such as the patient's cardiologist) and thephysiological condition of the patient (e.g., based on the patient'snormal resting heart rate, the patient's thoracic impedance, etc.)Alternatively, the level of current, the pulse width, and the frequencyof the pulses may simply be set to an appropriate value based on typicalimpedance values for an adult or child, and typical resting heart ratesfor an adult or child.

It should be appreciated that because pacing at a fixed rate mayinterfere with the patient's own intrinsic heart rate, the device can beconfigured to perform such fixed rate and energy pacing only in theevent of a life-threatening Bradyarrythmia, a lack of any detectedcardiac activity following shock, or in response to pulseless electricalactivity following shock.

2. Demand (Adjustable Rate) Pacing

In accordance with an aspect of the present invention, a medicalmonitoring and treatment device, such as the LifeVest® wearablecardioverter defibrillator, can also be configured to pace the heart ofa patient at a variable rate and a fixed energy in response to varioustypes of cardiac arrhythmias, including a bradyarrythmia (i.e., anexcessively slow heart rate), tachycardia (i.e., an excessively fastheart rate), an erratic heart rate with no discernible regular sinusrhythm, a lack of sensed cardiac activity (asystole), and pulselesselectrical activity. Some of these cardiac arrhythmias may occurfollowing one or more defibrillation shocks.

As known to those skilled in the art, pacing at a fixed rate and energymay not be appropriate to the particular type of cardiac arrhythmia ofthe patient, and even where the rate and energy level is appropriate,pacing at a fixed rate can result in competition between the rate atwhich the pacing pulses are being applied and the intrinsic rhythm ofthe patient's heart. For example, pacing at a fixed rate may result inthe application of a pacing pulse during the relative refractory periodof the normal cardiac cycle (a type of R wave on a T wave effect) thatcould promote ventricular tachycardia or ventricular fibrillation. Toovercome some of the disadvantages of fixed rate and energy pacing, themedical monitoring and treatment device can be configured to performdemand pacing, wherein the rate of the pacing pulses may be varieddependent on the physiological state of the patient. For example, duringdemand pacing, the device can deliver a pacing pulse only when needed bythe patient. In general, during the demand mode of pacing, the devicesearches for any intrinsic cardiac activity of the patient, and if aheart beat is not detected within a designated interval, a pacing pulseis delivered and a timer is set to the designated interval. Where thedesignated interval expires without any detected intrinsic cardiacactivity of the patient, another pacing pulse is delivered and the timerreset. Alternatively, where an intrinsic heart beat of the patient isdetected within the designated interval, the device resets the timer andcontinues to search for intrinsic cardiac activity.

FIG. 4 helps to illustrate some of the aspects of demand pacing and themanner in which demand pacing can be performed by the medical monitoringand treatment device. As illustrated in FIG. 4, the device may have avariable pacing interval 410 corresponding to the rate at which pacingpulses are delivered to the patient in the absence of any detectedintrinsic cardiac activity detected by the ECG sensing electrodes 112and ECG monitoring and detection circuitry. For example, the rate atwhich pulsing paces are to be delivered to the patient (referred to asthe “base pacing rate” herein) may be set at 60 PPM and therefore, thecorresponding base pacing interval 410 would be set to 1 second.

The medical monitoring and treatment device may also have a hysteresisrate (not shown in FIG. 4) corresponding to the detected intrinsic heartrate of the patient below which the device performs pacing. According tosome embodiments, the hysteresis rate is a configurable parameter thatis expressed as a percentage of the patient's intrinsic heart rate. Inthe above example, the hysteresis rate may correspond to 50 beats perminute (BPM). In this example, if the intrinsic heart rate of thepatient fell to 50 BPM or below (e.g., more than approximately 1.2seconds between detected beats), the device would generate and apply apacing impulse to the patient.

During application of a pacing pulse to the body of a patient and ashort time thereafter, the medical monitoring and treatment device mayintentionally blank out a portion of the ECG signals being received bythe ECG monitoring and detection circuitry to prevent this circuitry(e.g., amplifiers, A/D converters, etc.) from being overwhelmed (e.g.,saturated) by the pacing pulse. This may be performed in hardware,software, or a combination of both. This period of time, referred toherein as “the blanking interval” 420 may vary (e.g., betweenapproximately 30 ms to 200 ms), but is typically between approximately40 ms to 80 ms in duration.

In addition to the blanking interval 420, the medical monitoring andtreatment device can have a variable refractory period 430 that may varydependent upon the base pacing rate. The refractory period 430corresponds to a period of time in which signals sensed by the ECGsensing electrodes 112 and the ECG monitoring and detection circuitryare ignored, and includes the blanking interval. The refractory period430 allows any generated QRS complexes or T waves induced in the patientby virtue of the pacing pulse to be ignored, and not interpreted asintrinsic cardiac activity of the patient. For example, where the basepacing rate is set to below 80 PPM, the refractory period mightcorrespond to 340 ms, and where the base pacing rate is set above 90PPM, the refractory period might correspond to 240 ms. For typicalapplications, the refractory period is generally between about 150 msand 500 ms.

In accordance with an aspect of the present invention, the sensitivityof the ECG monitoring and detection that is performed by the medicalmonitoring and treatment device may also be varied to adjust the degreeby which the ECG sensing electrodes and associated ECG monitoring anddetection circuitry can detect the patient's intrinsic cardiac activity.For example, where the amplitude of certain discernable portions (e.g.,an R-wave) of a patient's intrinsic ECG signal is below that typicallyencountered, the voltage threshold over which this discernable portioncan be detected as belonging to an ECG signal (and not attributed tonoise or other factors) may be lowered, for example from 2.5 mV to 1.5mV, to better detect the patient's intrinsic cardiac activity. Forinstance, during an initial fitting of the medical monitoring andtreatment device, the sensitivity threshold of the device may be reducedto a minimal value (e.g., 0.4 mV) and the patient's intrinsic ECGsignals may be monitored. The sensitivity threshold may then beincrementally increased (thereby decreasing the sensitivity of thedevice) and the patient's intrinsic ECG signals monitored until theseECG signals are no longer sensed. The sensitivity threshold may then beincrementally decreased (thereby increasing the sensitivity of thedevice) until the patient's intrinsic ECG signals are again sensed, andthe sensitivity threshold of the device may be set to approximately halfthis value.

As with fixed energy and rate pacing, the device may be configured toprovide pulses at a fixed energy level and a fixed pulse width inresponse to detection of any of the above-noted events by the ECGsensing electrodes 112 and the ECG monitoring and detection circuitry.The maximum current level of the current waveform may be set to a valuebetween approximately 10 mAmps to 200 mAmps, the pulse width may be setto a fixed value between approximately 20 ms to 40 ms, and the base rateof the pulses may be set to a fixed value between approximately 30pulses per minute (PPM) to approximately 200 PPM, although the actualrate of the pacing pulses can vary based upon the intrinsic cardiacactivity of the patient. In accordance with one embodiment, a 40 msconstant current pulse is used, and the current level is set to a fixedvalue based upon the input of a medical professional, such as thepatient's cardiologist and the physiological condition of the patient.The base pacing rate and the hysteresis rate may also be set based uponthe input of the patient's cardiologist (or other medical professional)and the physiological condition of the patient, and the blankinginterval and refractory period set to an appropriate time interval basedupon the base pacing rate and/or the hysteresis rate.

Although the base pacing rate may be set to a particular value based onthe physiological condition of the patient and input from a medicalprofession, the medical monitoring and treatment device can include anumber of different pacing routines to respond to different cardiacarrhythmias, such as bradycardia, tachycardia, an erratic heart ratewith no discernable regular sinus rhythm, asystole, or pulselesselectrical activity. These pacing routines may be implemented using avariety of hardware and software components and embodiments are notlimited to a particular configuration of hardware or software. Forinstance, the pacing routines may be implemented using anapplication-specific integrated circuit (ASIC) tailored to perform thefunctions described herein.

A. Bradycardia

As discussed above, where Bradycardia is detected and the intrinsiccardiac rate of the patient is below that of the hysteresis rate, themedical monitoring and treatment device will pace the patient at thepre-set base pacing rate. During this time, the device will continue tomonitor the patient's intrinsic heart rate and will withhold pacingpulses in the event that an intrinsic heart beat is detected withindesignated interval corresponding to the hysteresis rate. This type ofon demand pacing is frequently termed “maintenance pacing.”

B. Tachycardia

For responding to tachycardia, the medical monitoring and treatmentdevice may additionally include another pacing rate, termed an“anti-tachyarrhythmic pacing rate” herein, above which the device willidentify that the patient is suffering from tachycardia, and will pacethe patient in a manner to bring the patient's intrinsic heart backtoward the base racing rate. For example, the device may employ atechnique known as overdrive pacing wherein a series of pacing pulses(e.g., between about 5 and 10 pacing pulses) are delivered to thepatient at a frequency above the intrinsic rate of the patient in aneffort to gain control of the patient's heart rate. Once it isdetermined that the device is in control of the patient's heart rate,the rate (i.e., the frequency) of the pulses may be decremented, forexample by about 10 ms, and another series of pacing pulses delivered.This delivery of pulses and the decrease in frequency may continue untilthe detected intrinsic cardiac rate of the patient is below theanti-tachyarrhythmic pacing rate, or at the base pacing rate. This typeof pacing is frequently termed “overdrive pacing” or “fast pacing.”

C. Erratic Heart Rate

For responding to an erratic heart rate, the medical monitoring andtreatment device may perform a type of pacing that is similar to acombination of maintenance pacing and overdrive pacing discussed above.For example, where the medical monitoring and treatment device detectsan erratic heart rate with no discernable sinus rhythm, the device maydeliver a series of pacing pulses (e.g., between about 5 and 10 pacingpulses) to the patient at a particular frequency. This frequency may beone that is above a lower frequency of a series of detected intrinsicbeats of the patient's heart and below an upper frequency of thedetected intrinsic beats of the patient's heart. After delivering theseries of pulses, the device may monitor the patient's heart todetermine if it has synchronized to the rate of the series of deliveredpulses. Where the intrinsic rate of the patient's heart is stillerratic, the device may increase the frequency of the series of pulsesand deliver another series. This may continue until it is establishedthat the patient's heart is now in a more regular state. Upondetermining that the patient's heart is now in a more regular state, thedevice may perform maintenance pacing if it is determined that thepatient's intrinsic heart rate is too low as discussed in section 2Aabove, or perform pacing at a decremented rate in the manner discussedin section 2B above, if such is warranted.

D. Asystole or Pulseless Electrical Activity

For responding to asystole or a detected condition of pulselesselectrical activity, the medical monitoring and treatment device mayperform maintenance pacing similar to that described in section 2Aabove. This type of pacing would be performed after a series of one ormore defibrillating shocks that attempt to restore a normal sinus rhythmto the heart of the patient.

In each of the above types of pacing, the medical monitoring andtreatment device may be configured to perform a particular type ofpacing only after a programmable delay after such cardiac arrhythmiasare detected, or after a programmable period of time after one or moredefibrillating shocks are delivered.

3. Capture Management

In accordance with an aspect of the present invention, a medicalmonitoring and treatment device, such as the LifeVest® wearablecardioverter defibrillator, can also be configured to pace the heart ofa patient using capture management with an adjustable energy level andan adjustable rate in response to various types of cardiac arrhythmias.The various types of cardiac arrhythmias can include a bradycardia,tachycardia, an erratic heart rate with no discernable regular sinusrhythm, a lack of sensed cardiac activity (asystole) following orindependent of one or more defibrillation shocks, a life-threateningBradyarrythmia following one or more defibrillation shocks, or pulselesselectrical activity following one or more defibrillation shocks.

As known to those skilled in the art, capture management refers to atype of pacing in which the energy level of pacing pulses and the rateof delivery of those pacing pulses may be varied based upon the detectedintrinsic activity level of the patient's heart and the detectedresponse of the patient's heart to those pacing pulses. In cardiacpacing, the term “capture” is used to refer to the response of apatient's heart to a pulse of energy which results in ventriculardepolarization. In cardiac pacing, it is desirable to limit the amountof energy in each pulse to a minimal amount required for capture;thereby minimizing the amount of discomfort associated with externalpacing.

In general, the manner in which the medical monitoring and treatmentdevice can perform capture management pacing is similar to that ofdemand pacing described above, in that it may adjust the rate at whichpacing pulses are delivered based upon the detected intrinsic rate ofcardiac activity of the patient. The sensitivity of the device to thepatient's ECG may be adjusted in a similar manner to that describedabove with respect to demand pacing. Further, capture management pacingmay be used to treat the same types of cardiac arrhythmias as the demandpacing described above, such as bradycardia, tachycardia, an erraticheart rate with no discernable sinus rhythm, asystole, or pulselesselectrical activity.

However, in contrast to a device that performs demand pacing, a devicethat is configured to perform capture management pacing will typicallyhave a refractory period 430 (see FIG. 4) that is significantly shorterthan a device configured to perform demand pacing. Indeed, when usingcapture management pacing, there may be no refractory period 430 at all,but only a blanking interval 420. Alternatively, where there is arefractory period 430, the refractory period 430 may be similar induration to the blanking interval 420. As would be appreciated by thoseskilled in the art, this is because during capture management pacing,the response of the patient's heart is monitored by the ECG sensingelectrodes 112 and ECG monitoring and detection circuitry to detectwhether the delivered pulse of energy resulted in capture. For thisreason, while the ECG monitoring and detection circuitry may be switchedoff or effectively disabled during the delivery of energy pulses, it isimportant that it be switched back on or otherwise enabled shortlythereafter to detect whether the delivered pulse resulted in capture. Inone embodiment in which a 40 ms constant current pulse is used, theblanking interval 420 may be set to approximately 45 ms to avoidsaturation of the ECG monitoring and detection circuitry, but ensurethat any intrinsic electrical activity of the patient's heart that wasinduced by the pacing pulse is detected.

During capture management pacing, the medical monitoring and treatmentdevice can deliver a pulse of energy at a determined energy level andmonitor the patient's response to determine if capture resulted. Whereit is determined that the delivered pulse did not result in capture, theenergy level of the next pulse may be increased. For example, where thedevice is a medical monitoring and treatment device that is external tothe patient, the initial setting may be configured to provide a 40 msrectilinear and constant current pulse of energy at a current of 40mAmps, and increase the amount of current in increments of 2 mAmps untilcapture results. The next pacing pulse may be delivered at increasedcurrent relative to the first pacing pulse and at a desired raterelative to the first pacing pulse in the absence of any detectedintrinsic cardiac activity of the patient. Where the next pacing pulsedoes not result in capture, the energy may be increased until capture isdetected. The medical monitoring and treatment device may then continuepacing at this energy level and at a desired rate in the absence of anydetected intrinsic cardiac activity of the patient. During this periodof time, the device monitors the patient's cardiac response to thepacing pulses, and may increment the energy level further, should it bedetermined over one or more subsequent pulses that capture did notresult.

In an alternative configuration, the medical monitoring and treatmentdevice may apply a series of pulses at an initial energy level and rate,and monitor the patient's response to determine if capture resulted.Where capture did not result, or where capture resulted in response tosome of the pulses, but not all, the device may increase the energy of anext series of pulses until capture results for each pulse.

Alternatively, the device may be configured to identify a minimum amountof energy that results in capture during capture management pacing.Where it is determined that the delivered pulse did result in capture,the energy level of the next pulse may be decreased. For example, wherethe device is a medical monitoring and treatment device that is externalto the patient, the initial setting may be configured to provide a 40 msconstant current pulse of energy at a current of 70 mAmps. Where it isdetermined that the delivered pulse resulted in capture, subsequentpacing pulses may be delivered and decreased in increments of 5 mAmpsand at a desired rate relative to the first pacing pulse in the absenceof any detected intrinsic cardiac activity of the patient until captureis no longer achieved. Where the next pacing pulse does not result incapture, the energy setting may be increased to the last current knownto produce a pulse resulting in capture, and then delivering a pulse atthe higher energy setting, thus delivering the minimal amount of energyrequired for capture. The medical monitoring and treatment device maythen continue pacing at this energy level and at a desired rate in theabsence of any detected intrinsic cardiac activity of the patient.During this period of time, a similar routine may be re-performed atpredetermined intervals to ensure that the minimum amount of energy isbeing delivered for capture. In addition, during this period of time,the device monitors the patient's cardiac response to the pacing pulses,and may increase the energy level should it be determined over one ormore subsequent pulses that capture did not result.

It should be appreciated that in the various embodiments describedabove, an external medical monitoring and treatment device has beendescribed which may not only provide life saving defibrillation orcardioversion therapy, but may also provide a wide variety of differentpacing regimens. Because the medical monitoring and treatment device canmonitor a patient's intrinsic cardiac activity, the patient's thoracicimpedance, and other physiological parameters of the patient, the devicemay be configured to recommend various settings to a medicalprofessional for review and approval. The various settings that may berecommended may include a recommended base pacing rate, a recommendedhysteresis rate, a recommended anti-tachyarrhythmic pacing rate, arecommended energy level (or initial energy level if capture managementis used), a recommended blanking interval, and/or refractory period, anda recommended sensitivity threshold. In the case of a medical monitoringand treatment device such as the LifeVest® cardioverter defibrillator,this initial recommendation may be performed when the patient is beingfitted for and trained on the use of the device.

Although the ability to recommend such settings to a medicalprofessional for their review and approval is particularly well suitedto a medical monitoring and treatment device, such as the LifeVest®cardioverter defibrillator, such functionality could also be implementedin an Automated External Defibrillator (AED) or an Advanced Life Support(ALS) type of defibrillator, such as the M Series defibrillator, RSeries ALS defibrillator, R Series Plus defibrillator, or E Seriesdefibrillator manufactured by the ZOLL Medical Corporation of ChelmsfordMass. It should be appreciated that monitoring the patient's intrinsiccardiac activity and other physiological parameters and makingrecommendations to a trained medical professional for their review andapproval (or possible modification) could reduce the amount of time thatis spent manually configuring such devices prior to use on the patient.

Having thus described several aspects of at least one embodiment of thisinvention, it is to be appreciated various alterations, modifications,and improvements will readily occur to those skilled in the art. Suchalterations, modifications, and improvements are intended to be part ofthis disclosure, and are intended to be within the scope of theinvention. Accordingly, the foregoing description and drawings are byway of example only.

What is claimed is: 1.-20. (canceled)
 21. A non-invasive bodily-attached ambulatory medical monitoring and treatment device comprising: at least one electro-cardiogram (ECG) sensing electrode configured to be disposed on a patient; at least one therapy electrode configured to be disposed on the patient; a treatment controller, coupled to the at least one ECG sensing electrode and the at least one therapy electrode, configured to sense a cardiac condition of the patient, to implement at least one pacing routine corresponding to the sensed cardiac condition, and to detect a discomfort of the patient during the at least one pacing routine.
 22. The device of claim 21, wherein the treatment controller is further configured to adjust at least one characteristic of the at least one pacing routine in response to the detected discomfort of the patient.
 23. The device of claim 22, wherein, the at least one characteristic of the at least one pacing routine includes at least one of an energy level of pacing pulses, a width of the pacing pulses, and a rate of the pacing pulses.
 24. The device of claim 21, wherein the treatment controller comprises a user interface configured to receive information from the patient descriptive of the discomfort.
 25. The device of claim 24, wherein the treatment controller is configured to detect the discomfort based on the information from the patient.
 26. The device of claim 24, wherein the user interface includes at least one patient response element, and wherein the user provides the information descriptive of the discomfort via the at least one response element.
 27. The device of claim 24, wherein the information descriptive of the discomfort comprises a voice signal from the patient.
 28. The device of claim 24, wherein the at least one patient response element comprises at least one button.
 29. The device of claim 24, wherein the at least one patient response element comprises a touch screen.
 30. The device of claim 24, wherein the at least one patient response element comprises a microphone.
 31. The device of claim 24, wherein the treatment controller is further configured to adjust at least one characteristic of the at least one pacing routine in response to the information from the patient.
 32. The device of claim 21, further comprising at least one motion sensor in communication with the treatment controller to detect motion of the patient during the at least one pacing routine.
 33. The device of claim 32, wherein the at least one motion sensor includes at least one of an accelerometer and an audio sensor.
 34. The device of claim 32, wherein the treatment controller is further configured to monitor the detected motion of the patient during the at least one pacing routine, and to detect the discomfort of the patient based on the detected motion.
 35. The device of claim 34, wherein the treatment controller is further configured to adjust at least one characteristic of the at least one pacing routine in response to the detected discomfort.
 36. The device of claim 34, wherein the at least one pacing routine includes at least one pacing pulse, and wherein the treatment controller is further configured to monitor the detected motion of the patient before, during, and after the at least one pacing pulse.
 37. The device of claim 36, wherein the treatment controller is further configured to adjust at least one characteristic of the at least one pacing routine in response to the detected discomfort.
 38. The device of claim 21, wherein the cardiac condition of the patient comprises at least one of Bradycardia, tachycardia, asystole, pulseless electrical activity, and erratic heart rate.
 39. The device of claim 21, wherein the at least one pacing routine comprises at least one of including fixed rate and fixed energy pacing, adjustable rate pacing, and capture management pacing.
 40. The device of claim 21, wherein the at least one pacing routine comprises a plurality of pacing routines, the plurality of pacing routines including at least two of fixed rate and fixed energy pacing, adjustable rate pacing, and capture management pacing.
 41. A non-invasive bodily-attached ambulatory medical monitoring and treatment device comprising: at least one electro-cardiogram (ECG) sensing electrode configured to be disposed on a patient; at least one therapy electrode configured to be disposed on the patient; a treatment controller, coupled to the at least one ECG sensing electrode and the at least one therapy electrode, configured to sense a cardiac condition of the patient, to implement at least one pacing routine corresponding to the sensed cardiac condition, to receive information indicative of patient motion during the at least one pacing routine, and to assess a level of discomfort of the patient during the at least one pacing routine.
 42. The device of claim 41, wherein the device further includes at least one motion sensor to provide the information indicative of patient motion to the treatment controller.
 43. The device of claim 41, wherein the at least one motion sensor includes at least one of an accelerometer and an audio sensor.
 44. A non-invasive bodily-attached ambulatory medical monitoring and treatment device comprising: at least one therapy electrode; a memory storing information indicative of a patient's cardiac activity; circuitry, disposed within the device and in communication with the at least one therapy electrode, for implementing a plurality of pacing routines, each pacing routine of the plurality of pacing routines corresponding to one or more cardiac conditions of a plurality of cardiac conditions; and at least one processor coupled to the circuitry, wherein the at least one processor is configured to identify, within the information, at least one cardiac condition of the plurality of cardiac conditions and respond to the identified cardiac condition in part by causing execution of at least one pacing routine corresponding to the identified cardiac condition.
 45. The device of claim 44, wherein the identified cardiac condition includes bradycardia and the at least one pacing routine is configured to: determine that a first interval has passed without detection of a heart beat; and apply, responsive to determining that the first interval has passed, a pacing pulse via the at least one therapy electrode.
 46. The device of claim 44, wherein the identified cardiac condition includes tachycardia and the at least one pacing routine is configured to: detect a plurality of intrinsic heart beats prior to passage of a first interval, the plurality of intrinsic heart beats having an intrinsic frequency, the first interval being defined by an anti-tachyarrhythmic pacing rate; and apply, responsive to detecting the intrinsic frequency, a series of pacing pulses via the at least one therapy electrode, the series of pacing pulses having a frequency above the intrinsic frequency.
 47. The device of claim 44, wherein the identified cardiac condition includes an erratic heart rate and the at least one pacing routine is configured to: identify a first series of heart beats within the information, the first series having a lower frequency; identify a second series of heart beats within the information, the second series a upper frequency; and apply, responsive to identifying the erratic heart rate, a series of pacing pulses via the at least one therapy electrode, the series of pacing pulses having a frequency above the lower frequency and below the upper frequency.
 48. The device of claim 44, wherein the identified cardiac condition includes at least one of asystole and pulseless electrical activity and the at least one pacing routine is configured to: determine that a first interval has passed without detection of a heart beat; and apply, responsive to determining that the first interval has passed, a pacing pulse via the at least one therapy electrode.
 49. The device of claim 44, wherein the at least one pacing routine is further configured to: determine whether the at least one pacing routine resulted in capture; and adjust, responsive to determining that capture did not result, the characteristics of pacing pulses applied during subsequent executions of the at least one pacing routine.
 50. The device of claim 44, wherein the at least one pacing routine is further configured to: determine whether the at least one pacing routine resulted in capture; and adjust, responsive to determining that capture did result, the characteristics of pacing pulses applied during subsequent executions of the at least one pacing routine. 